Background:Most of the
tobacco-attributable deaths are from combustible tobacco products. We explored
transitions from experimentation of different tobacco/nicotine products to
regular use of combustible products in a European population.

Methods:We analysed a representative sample of persons
aged ≥15 years from 28 European Union member states (Eurobarometer wave 87.1;
March 2017; n=27,901). Respondents who indicated ever trying tobacco/nicotine
products, including combustible products (boxed and hand-rolled cigarettes;
cigars/cigarillos; pipe; waterpipe); e-cigarettes; and smokeless products (oral/nasal/chewing
tobacco), were asked which product they first tried. Questions on history of
regular tobacco use (≥1-time weekly) were further asked to determine whether
ever tobacco users became established users at a point in their lifetime,
regardless of their current use status. We used multilevel logistic regression to
measure the association between first product tried and ever becoming an
established smoker of combustible tobacco (ESCT), adjusting for age, sex, area
of residence and financial difficulties We restricted analysis to those aged
< 40 years (n=8,125) to reduce differential smoking-attributable mortality
from different age cohorts.

Results:Overall, 58.7% of persons aged < 40 years
had ever tried a tobacco/nicotine product. Among these 79.7% first tried boxed
cigarettes, 7.0% hand-rolled cigarettes, 6.2% waterpipe and 1.9% e-cigarettes.
Compared to those who first tried e-cigarettes, the odds of ever becoming an
ESCT were higher among those who first tried boxed (aOR=3.50; 95%CI: 2.26-5.44) or
hand-rolled cigarettes (aOR=4.70; 95%CI: 2.74-8.04), but lower among those who first tried
waterpipe (aOR=0.30; 95%CI: 0.18-0.51). Adjusted odds did not differ
significantly among those who first tried pipe or smokeless tobacco compared to
first trial with e-cigarettes.

Conclusions:About 4
in 5 EU smokers first tried cigarettes, and these had increased likelihood of
becoming established combustible tobacco smokers in their lifetime. Exploring
reasons for experimenting with emerging products (e.g., e-cigarettes, hookahs)
can inform public policy.